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Case Report Natural Intracranial Hemorrhage and Its Forensic Implications: A

Case Review

Article in Journal of Indian Academy of Forensic Medicine · April 2014

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J Indian Acad Forensic Med. April-June 2014, Vol. 36, No. 2 ISSN 0971-0973

Case Report

Natural Intracranial Hemorrhage and Its

Forensic Implications: A Case Review
1 2 3 4
Punitha R, Pradeep Kumar M.V., Anand P Rayamane, Kalai Selvi L.T

Abstract
An aneurysm is an abnormal, weak spot in a blood vessel that causes an outward bulging or
ballooning of the arterial wall. An aneurysm confined to the head cause a serious medical condition, like a
hemorrhagic stroke, which leads to brain damage and death. Berry aneurysms are the most common
kind of aneurysm in the brain. The most common site of berry aneurysm is the anterior cerebral artery.
These aneurysms remain asymptomatic for a long time or may rupture and cause intracranial
hemorrhage and sudden death, there by arising suspicion in the eyes of his near and dear ones. In cases
of trivial trauma to head leading on to brain hemorrhage causing the death of the individual the defense
counsel takes the advantage of the aneurysm to be the cause of brain hemorrhage. This is a case, report
where deceased was found dead in bathroom, following rupture of berry aneurysm and we have reviewed
the literature regarding the berry aneurysm and tried to corroborate with the legal scenario.

Key Words: Berry aneurysm, Circle of wills, Subarachnoid hemorrhage, Sudden death

Introduction: The presence of berry aneurysm in a

An aneurysm is the dilatation of a case of head injury carries significance as to the
localized segment of the arterial system. origin of intracranial hemorrhage.
Morphologically, it can be saccular (also known This case report highlights a similar
as Berry aneurysm), fusiform or dissecting. [1] situation where an elderly female died due to
This localized dilatation is due to rupture of aneurysm suddenly.
deficiency in the tunica media leading to Case History:
weakness of the vessel wall. The Subarachnoid We received a dead body of female
hemorrhage (SAH) could be either traumatic or aged 45 years for post-mortem examination.
non-traumatic. The most common cause for According to the investigating officer she was
non-traumatic SAH is the rupture of aneurysm in found in an unconscious state in the bathroom
the brain. The incidence of berry aneurysm is and was taken to hospital, where she was
reported to be 2% and the incidence of declared as dead on arrival. Relatives of the
subarachnoid hemorrhage is 6-8/100000 person deceased did not have any knowledge regarding
years. [2] Aneurysms occur most commonly at the past medical history.
the junction of two arteries in the circle of Willis. Autopsy Findings:
Aneurysms are most commonly The deceased was moderately built &
saccular also called as berry aneurysm, and is nourished. Rigor noted throughout the dead
caused by head trauma in 1% of cases. [3] They body. Post-mortem lividity noted over the back
usually remain asymptomatic for a long time or surfaces of the body. Remaining external
may rupture and cause intracranial hemorrhage appearance was normal and unremarkable. No
and sudden death. Aneurysms are associated external injuries were found over the body.
with a high mortality rate. On internal examination, the scalp was
intact. Brain showed subdural hematoma &
Corresponding Author: diffuse subarachnoid hemorrhage. Subdural
2
Professor, hematoma was noted over base of brain. (Fig 1)
Department of Forensic Medicine A partial capsule of ruptured aneurysm
Raja Rajeswari Medical College & Hospital, was present at junction of anterior cerebral &
Kambipura, Bangalore - 560 074, Karnataka, India anterior communicating artery on left side. (Fig.
E-mail: [email protected]
1&4
Postgraduate student,
2) No atherosclerotic changes noted in the
3
Assist. Prof, Dept. of Forensic Medicine, remaining part of cerebral vessels. Heart walls,
MMCRI, Mysore valves and chambers were normal. Coronaries
DOR: 04.02.2014 DOA: 23.05.2014 were patent. Aorta showed mild atherosclerotic

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J Indian Acad Forensic Med. April-June 2014, Vol. 36, No. 2 ISSN 0971-0973

plaques. All the other organs were intact & reversed in rate of survival 30 days post rupture.
unremarkable. [14] About 60% of patients die immediately after
Discussion: rupture which was found in our case. [13]
Berry aneurysms, also known as But few studies suggest that survival
saccular aneurysms, are sac-like out-pouching after rupture lasted either less than one day or
in the cerebral blood vessels, which appear longer than one week. [15]
berry-shape on external examination, hence the In most of the studies home is the
name. Aneurysms usually reside in the Circle of common location at the onset of symptoms, and
Willis. [4] Rupture of aneurysm leads to sudden presence of associated physical exertion. [16]
death due to intracranial hemorrhage. [5] Patients with berry aneurysms more frequently
There are four main types of intracranial have histories of persistent headache,
aneurysms: saccular, fusiform, dissecting, pregnancy-induced hypertension, long-term use
and mycotic type. Saccular aneurysms occur of analgesics, and a family history of stroke. [17]
when there is collagen deficiency in the internal The pathogenesis of berry aneurysm
elastic lamina and breakdown of the tunica formation is multi-factorial. [18] The risk factors
media and accounts for 90% of intracranial for developing berry aneurysms include any
aneurysms. An out pouching, consisting of only condition that causes hypertension, including
tunica intima and adventitia, protrudes through atherosclerosis, renal disease or weakening of
the defect in the internal elastic lamina and blood vessel walls such as connective tissue
tunica media to produce the aneurismal sac. [6] disorders, infections, family history, smoking and
All studies to date show peaks at polycystic kidney disease. [19, 20]
various ages in the 40-70 year range, which is However, some controversy exists
consistent with our case where the age of the about the roles of underlying disease in the
deceased is 45yrs. [7] however a case of death rupture of cerebral artery aneurysms, particularly
due to a ruptured berry aneurysm has been hypertension and atherosclerosis.
reported in a 3.5 year old child. [8, 9] The prevalence of aneurysms is
With regard to sex, studies showed that increased in certain genetic diseases; the
men have a lower average age at time of rupture classic example is autosomal dominant
than women, with the difference between men polycystic kidney disease (ADPKD), but other
and women ranging from 2 to 4 years. It is diseases such as Ehlers-Danlos syndrome,
slightly more common in females, with the male: neurofibromatosis, and a1-antitrypsin deficiency
female ratio being 2: 3. [10] also demonstrate a link. [4] But in our case the
Rupture of these aneurysms leads to past medical history was not available and
hemorrhage in subarachnoid space and therefore cannot be correlated.
sometimes in brain parenchyma. The most Specific genes have also had reported
common pattern noted is subarachnoid association with the development of intracranial
hemorrhage alone, but hemorrhages in other aneurysms, including perlecan, elastin, collagen
areas are fairly common. [11] type 1A2, endothelial nitric oxide synthase,
But occasionally, an aneurysm may also endothelin receptor A and cyclin dependent
rupture into the subdural space, resulting in a kinase inhibitor. Recently, several genetic loci
subdural hematoma [12] Most of the studies have been identified as relevant to the
report that approximately 85% of cerebral development of intracranial aneurysms. These
aneurysms develop in the anterior part of the include 1p34-36, 2p14-15, 7q11, 11q25, and
Circle of Willis at the junction of anterior cerebral 19q13.1-13.3. [21]
& anterior communicating artery which is Forensic Significance:
consistent with our case. [4] Few studies also A thorough autopsy is an essential part
suggest that the middle cerebral artery was cited in the diagnosis of berry aneurysm. In cases,
as the location of most aneurysms. [13] where the death of the individual is due to
The exception was the study by intracranial hemorrhage, the question of natural
Inagawa and Hirano, who named the internal or unnatural causes has to be ruled out.
carotid artery as the most common location. [7] During autopsy the presence of
Aneurysms in the posterior half of the circle of intracranial hemorrhage accompanied by
Willis tend to have a significantly worse evidence of trauma like scalp contusion/fracture
prognosis than those in the anterior half. of skull bone rules out the natural causes.
Survival following rupture was poorer in The common cause of berry aneurysm
anterior circle aneurysms compared to posterior is hypertension, atherosclerosis etc., makes the
circle aneurysms; although the ratio was vessel prone for rupture. In such a scenario,

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 J Indian Acad Forensic Med. April-June 2014, Vol. 36, No. 2 ISSN 0971-0973

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Fig. 1: Hemorrhage over Brain Surface
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